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As a result of enrollment expansion, increasing numbers of students are entering into medical school in China. This combined with a shortage of teachers, means that the learning environment typically consists of a large classroom setting with traditional lecture-based learning (LBL) as the major mode to teaching and learning. In this article, we investigate the preferences for hybrid problem-based learning (hybrid-PBL) or LBL in a large classroom setting. Two hundred five second-year undergraduate students in Third Military Medical University were randomly divided to two groups. The hybrid-PBL group contained 101 students and was taught by hybrid LBL (60%) and tutor-less PBL(40%) in a large classroom. The LBL group consisted of 104 students and was taught by LBL in a large classroom too. Post-teaching performance was assessed by multiple choice questions, short-essay questions, and case-analysis questions, while the students' teaching preferences and satisfaction were assessed by questionnaires. Analysis of the results of both groups in the examination of biochemistry revealed significantly higher scores on short-essay questions and case-analysis questions in the hybrid-PBL group. Students considered hybrid-PBL to be an effective learning method and favored it over the lecture format. Furthermore, students reported positive effects of hybrid-PBL in terms of additional learning resources, critical thinking, and fun learning experiences. These results suggest that hybrid-PBL is better than the traditional LBL method at improving students' basic knowledge and problem-solving skills. Students preferred hybrid-PBL and were satisfied with it. The tutor-less PBL pattern in a large classroom setting may be feasible in Chinese medical schools. © 2012 by The International Union of Biochemistry and Molecular Biology, 41(1):5–10, 2013
China like many other countries has a shortage of doctors, as a result there has been a significant increase in the number of students entering medical school. At the same time there has been little increase in the amount of teachers. Together these factors result in traditional lecture-based learning (LBL) in a large classroom (over 100 students) as the major mode of teaching and learning in Chinese medical school . Although there are ways to liven up LBL and strategies to make it more effective, it is mostly passive learning . Lectures usually do not stimulate learners to construct explanatory models and to elaborate when acquiring new information, whereas modern theories of the learning and cognition emphasize the importance of active learning.
Over the past two decades, there has been a steady increase in the number of medical colleges with a problem-based learning (PBL) curriculum . The educational value and impact of using small group learning, a student-centered approach, and PBL have all been supported by both practice and research [4-6]. Today, experts in medical education largely agree that there are differences in the effects of PBL as compared with LBL. PBL is often favored over conventional education by both students and teachers. There is evidence which show that PBL is associated with a higher gain in medical competencies, in particular in interpersonal and cognitive domains [7, 8]. In addition, graduates of PBL curricula may retain their knowledge over a longer period of time and may be better prepared for life-long learning, that is keeping up with the development of medical knowledge .
Even though there is a significant body of evidence demonstrating the advantages of PBL over traditional LBL, a study has also suggested that PBL is not superior to LBL in all aspects of learning . Furthermore, most studies on the effectiveness of PBL originate from observations made in a small-group setting, usually involving five to nine students with a tutor supervising each group. Therefore, it cannot be assumed that introduction of PBL as a course delivery technique will automatically lead to enhanced student learning, especially in a large classroom setting with tutor-less groups. The superiority of PBL over standard course delivery techniques must be proven for each individual PBL delivery method.
Since traditional PBL delivery to small groups of students involves the supervision of group processes by a tutor, this methodology is associated with considerably higher costs when compared with traditional lectures given to large groups of students. Here, we describe an approach where PBL cases are delivered to large groups of up to 101 students facilitated by a single course instructor within undergraduate biochemistry courses. Our results show that this approach leads to increased student satisfaction. More importantly, the study that we conducted within a course delivered through a hybridization of PBL and LBL format showed a significant improvement of students' basic knowledge and problem-solving skills.
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In this study, we demonstrated that it may be feasible to implement hybrid-PBL as an educational strategy under the current conditions of a Chinese medical school. The hybrid-PBL approach in a large classroom setting has benefits for students' basic knowledge and problem-solving skills, as measured by written examination at the end of the semester. The results of our study therefore support earlier findings that hybrid-PBL is not only superior to LBL at students' basic knowledge but also at problem-solving skills .
The PBL students achieved better results in the categories of short-essay questions and case-analysis questions while no difference in the multiple-choice questions, which is consistent with Wolfram's results . This fact indicates that examination testing of more complex levels of knowledge, (i.e. on the comprehension or analysis level) is more appropriate for testing the outcome of PBL . An intra-group comparison of the three categories of questions further supported this hypothesis, revealing that students who had undergone the lecture-based course scored significantly lower in the short-essay part and case-analysis part, whereas their hybrid-PBL counterparts reached similar results in all categories of questions.
With regard to participation, both the hybrid-PBL group and LBL group keep a high participation rate in our study (Fig. 1). This result is not consistent with some previous reports [11, 13]. Since our university is a military medical school, all of the students are soldiers, and biochemistry is one of their basic medical training requirements, this may result in high participation.
When looking at the results of the questionnaires on students' preference for either of the two educational approaches, it is striking that a majority of the students in both groups would have preferred the hybrid-PBL course even before they had experienced it. Since PBL methodology was introduced in genetics and pathology courses before our study, and all students had received some general information on the method; we hypothesize that this preference for hybrid-PBL was an expressed attitude against the traditional system that the students were well acquainted with. After the course, however, the proportion of students favoring hybrid-PBL was increased in the hybrid-PBL group, indicating that those who now had a hybrid-PBL experience were not disappointed. Also, relatively more students changed their mind from LBL to hybrid-PBL than vice versa.
An important finding from the questionnaire distributed to the students in the hybrid-PBL course only, is the high level of students' satisfaction with the hybrid-PBL course. While the results of the questionnaire by no means provide an objective measurement of the strengths of hybrid-PBL, they do indicate that hybrid-PBL satisfies students' perceived needs in their education. In our opinion, student satisfaction by itself must be considered an important factor. It may be of particular importance that students were encouraged to extend their learning beyond the borders of the subject of biochemistry and to make use of additional learning resources .
Compared to classic PBL model, tutor-less PBL technique may be more suitable for Chinese medical school. Usually a large classroom setting with over 100 students and 1 teacher is the teaching and learning environment in Chinese medical school. The tutor-less PBL technique does not require additional tutors; therefore no additional funding is needed to implement this technique. To use this technique successfully, the instructor must be comfortable managing 8–10 groups of students during the open discussion phases of the PBL sessions which requires good facilitation skills. We estimate that up to 120 students could be managed by the technique described in this report. In classrooms with > 120 students, the process may break down because the time needed for group reports would create too much idle time for the majority of students . Guiding questions are needed to ensure that students identify learning issues . Attendance and fair distribution of workload are issues that require additional attention . Another advantage of PBL conducted in a large classroom compared with small-group sessions is that all students are exposed to the same case information during each session . This eliminates the need for the detailed tutor manuals that are typically used for the instruction of students in small tutor-led group meetings conducted in different rooms. In spite of the effect of tutor-less PBL, techniques on teaching and learning need to be further validated and evaluated, our results suggest that this technique can be used to improve the traditional large classroom LBL learning mode in Chinese medical school.
This study was approved by the Protocol Review Committee of the Undergraduate MD Programme and the Faculty of Health Sciences Research Ethics Board at Third Military Medical University.